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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br /> gC�FO'Rc� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FacilityInspection Date: <br /> Rf <br /> 1' ' /Ur M 'T.la . 61 <br /> Facilit A d d ress: Service Request#: <br /> /Onsite a ce Tec ian'sName: I Service Tech nici staller Exp. ate: Manufacturer� ming: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El EJ1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System Ll Other <br /> Leak detector <br /> Ll mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System Ll Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ electronic Serial: El El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System 111 Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El <br /> El fail safe Serial #: ❑ psi <br /> minutes <br /> El NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> AA VA"'ijI <br /> 7� S <br /> a <br /> THIS FACILI OBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH spec Rec7t_4��t <br /> : Title: <br /> / 1: LL vt cc c G-a <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/17//08 <br />